Provider Demographics
NPI:1275614828
Name:NEVILLE, BRAD WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:WESLEY
Last Name:NEVILLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 ASHLEY AVE
Mailing Address - Street 2:ROOM 544 BSB, DIVISION OF ORAL PATHOLOGY, MUSC
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-5070
Mailing Address - Country:US
Mailing Address - Phone:843-792-4495
Mailing Address - Fax:843-792-3697
Practice Address - Street 1:173 ASHLEY AVE
Practice Address - Street 2:ROOM 544 BSB, DIVISION OF ORAL PATHOLOGY, MUSC
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-5070
Practice Address - Country:US
Practice Address - Phone:843-792-4495
Practice Address - Fax:843-792-3697
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23751223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC002375Medicaid
SCT236980281Medicare ID - Type Unspecified
SC002375Medicaid